Laserfiche WebLink
APPLICATION <br /> SAN JOAQUIN COUNTY PJBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ;1445 N SAN JOAQUIN, PHONE (209)468-3420 <br /> - P O BOX 2009, STOCKTON, CA 95201 <br /> 3',PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application to hereby made to Sac Joaquin County for a'permit to construct and/or install the work herein described. This <br /> application Is made in compliance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Seervpicces. <br /> Job Address 107-5 s9•- Ol/ City��!� — Lot.Size/Acreage S <br /> Owner's Name 1&Otr yr!>G�PS Address ZAV00 & Phone 7S <br /> ConuactorTU YherEJ � Address } ' ffw&440V 40&04. License No. �, Q Phone5�P�110ZZ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT'n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑' Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK AJIA� SEWER LINES y7—;*' _- - DISPOSAL FLD. AI <br /> FOUNDATION � � AGRICULTURE WELL A?/* OTHER WELL PROP. LINE <br /> PITS/SUMPS <br /> TINTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �. <br /> i <br /> 0 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I/V <br /> ,F�Domestic/Private ❑ Gravel Pack ❑ Tracy 'Type of Casing— G Specifications <br /> I'1 Public 1'1 Other fl Delta Depth of Grout Seal IO Type of Grout19W0 1} <br /> t I Irrigation _Approx.!iDepth /N4 Eastern Surface Seal Installed by e ob-14, <br /> k, <br /> Repair Work Done U Type of Pump H.P. State Work one <br /> Well Destruction ❑ Well Diameter Sealing Material. A Depth� N/]F��1� <br /> Depth Filler Material'& Depth 000 ! _ _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 I REPAIR IADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is _T <br /> a available within 200 feet.) <br /> Installation will serve: Residence T Commercial_ Other !e' <br /> Number of living units: Number of bedrooms v <br /> Character of soil to a depth of 3 feet:? Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg, Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ i Method of Disposal <br /> Distance to nearest: Well foundation Property Line <br /> LEACHING LINE ❑ No. & Len'gth of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Founaanan Property Line <br /> SEEPAGE PITS 11 Depth i° Size Number <br /> w <br /> SUMPS CI Distance toy nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ f <br /> I hereby certify that I have prepared this"application and that the work will be'done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Horne owner or licensed agent's signature cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> cenifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." t <br /> The applican st 1 156576requirodAspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> s' I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ Date Area <br /> Pit or Grout Ins �J <br /> pection by Date Final Inspection by Date <br /> Addition! Comments: �� S d(p fh7 i� r, /�/? <br /> Applicant - Return all copies to: Sao-Joaquin Coun y Public Health Services <br /> 1, Environmental Health Permit/Services ? 1 <br /> 445 N San Joaquin, P 0 Box 2009, Stkn, CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED By DATE PERMIT-No. <br /> INFO �} / <br /> • EN13-241REV.r/n61 � .N ! 0~ <br /> E!1 11.20 V <br />